Direction Générale

Disease Management DEVELOPMENT

The Independent Health Insurance Funds

Brussels,05.07.2010

Réunion - Date

2

Strategic context

1. Why introducing DM ?

Challenges on the macro-level:

Dramatic increase of the number of patients with chronic conditions;

High costs to health and social systems

Improve care quality

Improve efficiency in use of the available resources for treatment of chronic diseases

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3

Strategic context

Why introducing DM ? (2)

Challenges on the process-level:

Systematizing the use of guidelines by physicians

Improving coordination of care

Improving patient compliance in medication and life style adoption

Systematizing the use of ICT in care

Systematizing data input/analytics on treatment process and outcome

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4

Strategic context

Disease Management Company Vision

Integration NeedMedical Integration Mgmt Information Integration MgmtFinancial Resources MgmtDaily operations Mgmt

New entity of Disease Management

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5

Unique position MLOZ and NM in HCS

Free and independant from others

20% of market

Fast growing (2.4%)

Open for new partnerships with providers, industry

Innovation central strategy

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6

Strategic context

Disease Management CompanyVision

Integrated Care Solutions =

IT supported Care Path + Medical Call centre

New elements of care:

A. Enrolment system based on the risk stratification and the Evidence Based Practice Guidelines

B. Patient self management support tools

C. Providers support tools (IT based)

D. Process and outcomes measurement

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7

Strategic context

Activities

1. Care plans development – integration/relation other initiatives

2. Individual Care plan management

3. Education/coaching/monitoring for each pathology and combined pathologies

4. Care plans IT support and maintenance

5. Promotion of care plans and IT support with physicians

6. Training of physicians in system use

7. Facilitating of medical telephone support to patients outsourcing with Home Care/Call centre’s

8. Data processing and analysis

9. System quality monitoring and care plans upgrading

10. Communication

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8

Strategic context

Services

Patient <= individualized health path; personal electronic record with variety of tools (information/ education/ coaching/monitoring/ authorization and sharing)

Physicians <= availability of the evidence based clinical guidelines/E-learning/ secure information exchange within the Care Teams / decision support

Health Insurer <= services for members/ process en outcome measurements/efficiency tools

Réunion - Date

9

Disease Management Development Program From Consortium to DMC

Conso

rtiu

m

RequirementAnalysis

Preconditions Project Execution

ProjectDelivery

DMC Services

DMCCommunication

DMC DEVELOPMENT

DM C implementation

DMC OPERATIONS

P0: DMC operatingsystem

requirements & architecture

P1: Tele-Coaching Service Dvpt

DMC legal advise &Foundation

DMCBusiness

plan

DMCInstallation

MOU April 2010

Conso

rtiu

m N

egoti

ati

ons

Agreement IJune

2010

DMCOperations&

Marketingplan

Market Launch 1st Q 2011

Agreement II 1st Q 2011

GPConsultation

Enrolement DM

PT Informed consent

Education/coaching

DietcianMove

DMCare Plan

Agreements GP - DM

Stop

DM planning

Mediscal Follow -up

CoordinationPlanningFeedback

Technical equipment

Monitoring InformationCall centre

Social linkWelfare

Pharmacist

Pharmacist

Specialist Lab Hospital

Specialist Nurse Pharmacist HIF DATA

DM analysis

Po

D M C

Solutions Projects

ConsortiumOthersS

uppl

iers

Inte

gra

tor

Co

ord

inat

or

Cus

tom

ers

GP associatons

HospitalsNurses

associations

GP’s Specialists Nurses

Pharmacistassociations

Pharmacies

HIF’s;Companies

Patients

Strategic context Value chain model

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12

Strategic context

Goals

1. Build a Disease Management System and integrate the existing applications/ initiatives into the system (focus on the selected pathologies)

2. Facilitate political lobbying for the implementation of this solution (financing/ legal framework/ adoption by professionals and patients)

3. Create Disease Management Company to bring Solutions to the market

Direction Générale

2. Governance

Advisory Board

Consortium

DMC

Réunion - Date

14

Governance

2.1. Consortium Structure

Steering Groep Advisory Board (CEO’s/staff of member organizations) (political opinion leaders)

Consortium Management Staff(Project Managers) Office Manager

Financial Controller

Project GroupsMedical

ITBusiness

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15

Governance

2.2.Advisory board

The role of the advisory board is to give strategic advice and to ensure political endorsement. The advisory board has the important task to put some political pressure on the insurance committee. This paritary committee is responsible for taking decisions whether to reimburse certain activities or not. In order to get structural reimbursements from RIZIV for the services delivered by DMC, the advisory board has to play an active role in the negotiations with this committee.

The following persons will be part of the advisory board: Bernadette Adnet (Staff member VBO) Yolande Avontroodt (Member of the federal parliament and president of the

management committe of RIZIV) Jo De Cock (General manager RIZIV) Pascal Mertens (General manager MLOZ) Dirk Ramaekers (Medical director ZNA) Michel Vermeylen (General practitioner and vice-president ABSYM) Jan Van Acker (President Pharma.be)

Advisory Board

Consortium

DMC

Réunion - Date

16

Governance

2.2.Advisory board2.2.1.Feedback meeting 21/1 (1)

Services : IT and individual acces

Online data, decision support and suggestions for the GP

Coaching as support for the GP

Telehealth tools – PHR

Homecare functionalities

Social services

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17

Governance

2.2.Advisory board2.2.1. Feedback meeting 21/1 (2)

Structure : New structure needed Mixed governance National institute supervision Quality system to be developped

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18

Governance

2.2.Advisory board 2.2.1.Feedback meeting 21/1 (3)

Support by members of AB : Endorsement and communication/marketing

ABSYM/BVASPolitical - legal support and framework Privacy commissionCommunication and promotion

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19

Feedback advisory board (4.06.2010)

Quality is critical success factor- validation – performance assessment

Legal support for IT necessary

Start mean and lean in socio-demographic advantaged areas

Education/coaching at short term

Not for profit structure necessary

Réunion - Date

20

Governance

2.3.Consortium Principles

The consortium is a temporary partnership between users and suppliers of disease management solutions. Their task is to:

Build a Disease Management System and integrate the existing applications/ initiatives into the system (focus on the selected pathologies)

Facilitate political lobbying for the implementation of this solution (financing/ legal framework/ adoption by professionals and patients)

Create Disease Management Company to bring Solutions to the market

The Consortium has the decision power to initiate projects.

The Consortium consists of three major groups 2 health insurance funds Care providers IT suppliers

Other parties that will play an important role are Associated partners that can provide support during the different projects. These partners

can share their know-how, tools or can contribute financially; Suppliers who provide specific tools (e.g. IT tools).

The procedure to enter and exit a partnerships has to be decided by the consortium.

Advisory Board

Consortium

DMC

Réunion - Date

21

Governance

2.3.Consortium2.3.1.Daily management

Management General Manager : Jan Van Emelen – strategy, communication, medical

work packages Operational Program Manager : Irina Odnoletkova: global program

manager, busines projects, education and coaching IT program manager : Louis Schilders: IT architecture, standard,

integration, applications Staff (financial officer, office manager)

The daily management will execute the consortium program as presented today. The Program starts the day the MOU is signed.

The daily managemen reports to the steering committee. It has to be decided how frequently the steering committee meets.

The consortium functioning is financed by the partners.

Réunion - Date

22

Governance

2.4. Disease Management Company- DMC

DMC is an independent and executive cooperation that facilitates the integration of health care.

The development of DMC will be supported by the consortium members, public and government funds (article 56) and other project-based financing.

In a later stage financing should happen through structural reimbursement, patient contributions and contributions from companies using the DMC services.

The DMC will have a classic corporation structure to run its operations

A governance structure for DMC has to be determined. Which parties should be represented in the Board of DMC and what the different roles and responsabilities are, will need to be defined in the DMC Company setup.

Advisory Board

Consortium

DMC

Marketpotential

Time Commercial Services RIZIV Structural Reimbursement and projects

Compulsory Insurance Adjustment Proposal

Governance2.4. DMC

2.4.1. Market Penetration Strategy

Réunion - Date

24DM 2010/0226

How to achieve the State reimbursement?

DMC set-up and System Evaluation Design should be

ruled by HIF’s :

• MLOZ and • Neutral HIF

Health Care Providers Associations : • ABSYM, • APB

Governance

2.4. DMC2.4.2. Political strategy

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25

3. Program Management

Réunion - Date

26

Disease Management Development Program From Consortium to DMC

Conso

rtiu

m

RequirementAnalysis

Preconditions Project Execution

ProjectDelivery

DMC Services

DMCCommunication

DMC DEVELOPMENT

DM C implementation

DMC OPERATIONS

P0: DMC operatingsystem

requirements & architecture

P1: Tele-Coaching Service Dvpt

DMC legal advise &Foundation

DMCBusiness

plan

DMCInstallation

MOU April 2010

Conso

rtiu

m N

egoti

ati

ons

Agreement IJune

2010

DMCOperations&

Marketingplan

Market Launch 1st Q 2011

Agreement II 1st Q 2011

Réunion - Date

27

Management Structure

Program Manager Irina Odnoletkova

Project Manager P0 (to be appointed)

DMC Foundation

Project Manager DMC Communication (to be appointed)

Education&Coaching

Development

Consortium Steering BoardPolitical Advisory

Board

Program Sponsor: Jan Van Emelen

WP1 WP2 WP3 WP4 WP5 WP6 WP7Stratification Informed consent Medical reference Careplan Com/feedback Evaluation Edu&Coach

Réunion - Date

28

DMC Legal Advise &

Foundation

DMC Value: Offering

Tele-health Services To the whole Belgian

Populatian (patients and health care

providers)

DMC preconditions definition(by future DMC owners:Independent HIF’s; Neutral HIF’s; Political Physician Association; National Pharmacist Assotiation)

Legal and Financial/Fiscal Advise

Final Agreement by future owners, andCompany Foundation

DMC Foundation

Mei 2010 June 2010 July 2010

Réunion - Date

29

DMCCommunication

Development of consequent

CommunicationStrategy and Plan

With all stakeholders

Stakeholders Identification

TO WHOM?

Communication Strategy Development

WHAT?

Communication Plan Development

HOW?

DMC Communication

Mei 2010 June 2010 July 2010

Réunion - Date

30

P0: DMC Enterprise ArchitectureBusiness, System and Technical

blueprints

Business architecture• Strategy• Medical-functional

analysis• Business analysis

System architecture• Data • Application • Infrastructure• Integration

Technical architecture• Standards • Services

DM

C o

pera

ting

syst

em r

equi

rem

ents

& a

rchi

tect

ure

BA Blueprint September 2010

AA+DA BlueprintOctober 2010

TA Blueprint December 2010

By

Independent

Experts

By Consortium Partners

Réunion - Date

31

GPConsultation

Enrolement DM

PT Informed consent

Education/coaching

DietcianMove

DMCare Plan

Agreements GP - DM

Stop

DM planning

Mediscal Follow -up

CoordinationPlanningFeedback

Technical equipment

Monitoring InformationCall centre

Social linkWelfare

Pharmacist

Pharmacist

Specialist Lab Hospital

Specialist Nurse Pharmacist HIF DATA

DM analysis

Po

Réunion - Date

32

Po

Architecture Blueprints

ArchitectureGuiding Principles

Metrics & Measurement

Architecture Repository

Blueprints describe the business requirements and technology components in a way that enables their linkages to be traced from business owner to system developer.

Architecture Guiding Principles serve as guideposts for strategic and tactical technology decision-making.

Architecture Processes document how architecture design is performed and implemented in the organization.

Metrics & Measurements describe the quantitative and qualitative goals for the enterprise architecture to ensure that value is measured and communicated.

Architecture Governance is a comprehensive set of policies, processes and procedures that ensure proper, yet flexible, guidance and approval checkpoints for architecture.

Architecture Repository is the control point for all architectures assets –blueprints, processes, metrics. The repository is accessed and managed through the architecture toolset.

Organization & Skills details the structure, capabilities and qualifications needed to build, maintain, and implement the architecture.

ProgramDMC Enterprise Architecture Development

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BusinessStrategicPlanning

EnterpriseArchitectureBlueprinting

Project Release Planning

Portfolio Mgmt

Project Execution

Business Operations

Metrics

Approved Projects

As-Built architecture

EA Governance

Objectives&measurements Indicators

Architecture benefits results

Business benefits results

Program

DMC Lifecycle

Réunion - Date

34

Programme

IT Architecture (1)

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35

Programme

IT Architecture (2)

WEB Based Architecture

Security & confidentiality – Authentication of patients & Healthcare Professionals (eHealth & EID) Authorisation (standard eHealth – application/disease specific DMC)

Patient Informed Consent

Upload of Medical Patient Summary (cross diseases)

Collection of disease specific parameters/values

Secured Sharing of information both medical and personal between members of the Care Team

Education of enrolled patients – eLearning - ZorgTV

Coaching of enrolled patients – Personal Health record

Réunion - Date

36

Coaching&Education Service Development

Functional Requirements & Preconditions Analysis

Make or buy?Fit into the System

Design? Service Development

•Operational plan•Marketing Plan

Service Implementation

Co

ach

ing

&E

du

cati

on

Ser

vice

Dev

elo

pm

ent

September 2010 December 2010Market Launch 1st Q 2011

The objective is to develop Services • B2B2C to members of MLOZ&NZ – via complementary insurance products (25% of the Belgian market) • B2C – to non-members.The Service will be offered to other HIF’s on B2B2C basis.

Réunion - Date

37

International trend in chronic care

90% of chronic care = selfcare Symptoms monitoring + appropriate actions (adjust medications,

schedule a doctor visit); Major lifestyle changes (e.g., stop smoking, reduce alcohol consumption,

modify diet, lose weight, and increase exercise); Medication compliance; Office visits for lab tests, physical exams, and clinician consultations.

=> Self-Management Support is necessary!

Telecoaching aims to change patient behavior

Réunion - Date

38

Self-management support

is “the systematic provision of education and supportive interventions by health care staff to increase patients’ skills and confidence in managing their health problems, including regular assessment of progress and problems, goal setting, and problem-solving support.”

Réunion - Date

39

Chain of self-management support effect

Patient Behaviour

Disease Control

Health Outcomes

Patient Satisfaction

Health Care Utilization

Less Costs

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40

Own experience: pilote project CareTV

Problem with patient education paid by RIZIV

(diabetes 2): too late no standard efficiency loss on nurse traveling Information “push”

Preliminary conclusion CareTV: Distant coaching is feasible; Travel time becomes patient contact time; Individual coaching based on behavioral change theory is efficient

Réunion - Date

41

Design Options for a Self-Management Support Program

Place within the health care system (who offers the service?)

Enrolment procedure

Role and background of the coaching staff

Content of the support

Patient population served

Communication tools (Website/ telefone/ combination)

Protocols for how staff is to provide the support.

Staff training

Communication between physicians and coaching staff

Réunion - Date

42

Target groups

Belgium MLOZDiabetes 500.000 95.000Asthma 600.000 114.000COPD 385.000 73.150Cardiovascular 400.000 76.000Cancer 300.000 57.000Depression 900.000 171.000TOTAL 3.085.000 586.150PregnancySmokersetc.

• Patients

• GP Circles: +/-260• Hospitals: +/- 250• Data collectors: Pharmaceutical industry, IMS, Cegedim, academic centres, scientific organizations

Réunion - Date

43

P0: DMC Enterprise ArchitectureBusiness, System and Technical

blueprints

Business architecture• Strategy• Medical-functional

analysis• Business analysis

System architecture• Data • Application • Infrastructure• Integration

Technical architecture• Standards • Services

DM

C o

pera

ting

syst

em r

equi

rem

ents

& a

rchi

tect

ure

BA Blueprint September 2010

AA+DA BlueprintOctober 2010

TA Blueprint December 2010

By

Independent

Experts

By Consortium Partners

L’Union Nationale des Mutualités Libres regroupe :